Why making some noise may keep the cash coming

While the public stay committed to the NHS, the government must listen

Chancellor Gordon Brown's multi-billion pound announcement this week will doubtless raise hopes and expectations across the NHS (See News, page 2). It certainly provides financial stability. Yet it is also clear that health secretary Frank Dobson's hands will be tied on how a substantial chunk of the money is used. When Mr Dobson stands up today to tell us what he plans to do with it, his announcement will largely reflect not the priorities of his department or of the NHS, but those agreed between prime minister Tony Blair and his chancellor.

In some respects these will coincide. But there has been evidence over the past year that the 'politics of the headline' are distorting healthcare priorities. The emphasis on waiting lists rather than waiting times, and the 'lock 'em up' approach to mental health are two obvious examples.

Ministers pursue these policies, while informed opinion looks on aghast, because in these days of ideology-free government such policies are thought to appeal to the disaffected Tory voters who gave Labour its majority.

Mr Blair's presidential-style oversight of policies is a matter of some concern too, not least because it transforms the balance that secretaries of state must maintain - between good management of the service and the political necessity of winning the next election - into a single-minded emphasis on the latter objective.

But this can be made to work in the interests of the health service - at least for as long as people remain concerned about the NHS's well-being. It need not mean constant claims of crises, but neither, to use the language of a previous regime, is it in the service's interest to 'keep the noise down'.

The moral for managers is clear: shroud-waving may not be acceptable, but neither will it help to pretend that the NHS is ever a problem-free zone. A little honest discussion of the what is and what is still not possible, and of the hard choices that remain - despite Mr Brown's billions - is only prudent.

Financial penalties are being lifted from high-profile standards including cancer and elective waiting times, so far without attracting much attention. How is this happening? And will it work, asks Rob Findlay